STANDARD INSURANCE COMPANY

Transcription

1 Policyholder: STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon (503) CERTIFICATE: GROUP SHORT TERM DISABILITY INSURANCE Policy Number: Portland Police Association Effective Date: October 1, 1997 A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. GC190-STD

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3 Table of Contents COVERAGE FEATURES... 1 GENERAL POLICY INFORMATION... 1 BECOMING INSURED... 1 PREMIUM CONTRIBUTIONS... 2 SCHEDULE OF INSURANCE... 2 DISABILITY PROVISIONS... 3 EXCLUSIONS AND LIMITATIONS... 3 OTHER PROVISIONS... 3 INSURING CLAUSE... 4 DEFINITION OF DISABILITY... 4 RETURN TO WORK INCENTIVE... 4 TEMPORARY RECOVERY... 4 WHEN STD BENEFITS END... 5 PREDISABILITY EARNINGS... 5 DEDUCTIBLE INCOME... 6 RULES FOR DEDUCTIBLE INCOME... 6 BENEFITS AFTER INSURANCE ENDS OR IS CHANGED... 7 EFFECT OF NEW DISABILITY... 7 EXCLUSIONS... 7 LIMITATIONS... 7 CLAIMS... 8 ALLOCATION OF AUTHORITY TIME LIMITS ON LEGAL ACTIONS INCONTESTABILITY PROVISIONS WHEN YOUR INSURANCE BECOMES EFFECTIVE ACTIVE WORK PROVISIONS WHEN YOUR INSURANCE ENDS REINSTATEMENT OF INSURANCE DEFINITIONS... 13

4 Index of Defined Terms The page number shown below is where the term is defined. For terms defined by an entire section, the page number below is the page on which that section begins. Active Work, Actively at Work, 12 Return To Work Incentive, 4 Benefit Waiting Period, 13 Class Definition, 2 Contributory, 13 Sickness, 14 STD Benefit, 14 Temporary Recovery, 4 Deductible Income, 6 Disability, 4 Disabled, 4 War, 7 Work Earnings, 4 Eligibility Waiting Period, 13 Employer(s), 1 Evidence of Insurability, 13 Group Policy, 14 Group Policy Effective Date, 1 Injury, 14 Leave of Absence Period, 3 Maximum Benefit Period, 14 Maximum STD Benefit, 3 Member, 1 Minimum, 3 Noncontributory, 14 Partial Disability Income Percentage, 3 Partially Disabled, 4 Physician, 14 Policyholder, 1 Predisability Earnings, 5 Pregnancy, 14 Prior Plan, 14 Proof Of Loss, 8

5 COVERAGE FEATURES This section shows many of the features of your short term disability (STD) insurance. Other provisions, including exclusions, limitations, and Deductible Income, appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number: Policyholder: Portland Police Association Employer(s): City of Portland, Oregon Group Policy Effective Date: October 1, 1997 Policy Issued In: Oregon BECOMING INSURED To become insured you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Active Work Provisions and When Your Insurance Becomes Effective. Definition of Member: You are a Member if you are either A. or B. below: A. You are a Member if you are regularly working at least 30 hours each week, a citizen or resident of the United States or Canada, and one of the following: 1. A Portland Police Association bargaining unit PERS member who was insured under Standard group policy on December 31, 1992; or 2. An active sworn police officer of the Employer, and one of the following: a. A member of the Portland Police Association bargaining unit; or b. A member of the Portland Police Association who (a) was insured under the group policy as a member of the Portland Police bargaining unit on the date immediately prior to promotion to Lieutenant or Captain, and (b) who elects to remain insured under the group policy instead of becoming insured under Standard group policy B. You are a Member if you are regularly working at least 20 hours each week, a citizen or resident of the United States or Canada, and one of the following: 1. A Portland Police Association bargaining unit PERS member who was insured under Standard group policy on December 31, 1992 and who is on job share; or 2. An active sworn police officer of the Employer, and one of the following: Printed 7/1/2003 1

6 a. A member of the Portland Police Association bargaining unit; or c. A member of the Portland Police Association who (a) was insured under the group policy as a member of the Portland Police bargaining unit on the date immediately prior to promotion to Lieutenant or Captain, and (b) who elects to remain insured under the group policy instead of becoming insured under Standard group policy You are not a Member if you are: 1. A temporary or seasonal employee; or 2. A full-time member of the armed forces of any country. Class Definition: Eligibility Waiting Period: Evidence Of Insurability Class 1: Members with 10 or more years of service with the Employer who choose to reduce their hours from working at least 30 hours each week to working at least 20 hours each week, and who becomes disabled during the first 12 months of reduction of their hours. Class 2: Members with less than 10 years of service but at least 18 months of service with the Employer who choose to reduce their hours from working at least 30 hours each week to working at least 20 hours each week, and who becomes disabled during the first 12 months of reduction of their hours. Class 3: All other Members with 10 or more years of service with the Employer. Class 4: All other Members with less than 10 years of service with the Employer. You are eligible on one of the following dates: If you are a Member on the Group Policy Effective Date, you are eligible on that date. If you become a Member after the Group Policy Effective Date, you are eligible on the date you become a Member. Required: a. For late application for Contributory insurance. b. For reinstatements if required. c. For Members eligible but not insured under the Prior Plan. PREMIUM CONTRIBUTIONS Insurance is: Contributory SCHEDULE OF INSURANCE STD Benefit: 60% of the first $1,925 of your Predisability Earnings, reduced by Deductible Income. Printed 7/1/2003 2

7 Maximum: Minimum: $15 Benefit Waiting Period: Maximum Benefit Period: $1,155 before reduction by Deductible Income. 29 Days for Disability caused by accidental Injury. 29 days for Disability caused by Sickness or Pregnancy. 180 days minus the length of the Benefit Waiting Period. If you are Disabled for less than one full week, we will pay one-seventh of the STD Benefit for each day of Disability. Partial Disability: See Definition Of Disability for more information. DISABILITY PROVISIONS Covered. The Partial Disability Income Percentage is 60% of your Predisability Earnings. EXCLUSIONS AND LIMITATIONS Work Related Disability Exclusion: Yes See Exclusions and Limitations for this and other exclusions and limitations. OTHER PROVISIONS Leave Of Absence Period: Predisability Earnings based on: 30 days or less. Class 1 & 2: Earnings in effect on your last full day of Active Work regularly working at least 30 hours each week. Class 3 & 4: Earnings in effect on your last full day of Active Work. Printed 7/1/2003 3

8 INSURING CLAUSE If you become Disabled while insured under the Group Policy, we will pay STD Benefits according to the terms of the Group Policy after we receive satisfactory Proof Of Loss. ST.IC.01 DEFINITION OF DISABILITY You are Disabled if you meet either of the following definitions: A. Definition Of Disability; or B. Definition Of Partial Disability. A. Definition Of Disability You are Disabled if, as a result of Sickness, Injury or Pregnancy, you are unable to perform with reasonable continuity the material duties of your own occupation. B. Definition Of Partial Disability You are Partially Disabled when you work for your Employer but, as a result of Sickness, Injury or Pregnancy, are unable to earn more than the Partial Disability Income Percentage shown in the Coverage Features. One half of your Work Earnings will be Deductible Income. See Return To Work Incentive and Deductible Income. ST.DD.01 A. During The Benefit Waiting Period RETURN TO WORK INCENTIVE You may serve your Benefit Waiting Period while working for your Employer, if you meet either the Definition Of Disability or the Definition Of Partial Disability. B. After The Benefit Waiting Period You are eligible for the Return To Work Incentive on the first day you work for your Employer after the Benefit Waiting Period if STD Benefits are payable on that date. One half of your Work Earnings will be Deductible Income. Work Earnings means your gross weekly earnings from work you perform for your Employer while Disabled. ST.RW.01 TEMPORARY RECOVERY You may temporarily recover from your Disability during the Maximum Benefit Period, and then become Disabled again from the same cause or causes, without having to serve a new Benefit Waiting Period. Temporary Recovery means you cease to be Disabled for no longer than the allowable period. Printed 7/1/2003 4

9 A. Allowable Period The allowable period of recovery during the Maximum Benefit Period is a total of 30 days. B. Effect Of Temporary Recovery If your Temporary Recovery does not exceed the allowable period, 1 through 4 below will apply. 1. The Predisability Earnings used to determine your STD Benefit will not change. 2. The period of Temporary Recovery will not count toward your Maximum Benefit Period. 3. No STD Benefits will be payable for the period of Temporary Recovery. 4. Except as stated above, the provisions of the Group Policy will be applied as if there had been no interruption of your Disability. ST.TR.05 WHEN STD BENEFITS END Your STD Benefits end automatically on the earliest of 1 through 5 below. 1. The date you are no longer Disabled. 2. The date your Maximum Benefit Period ends. 3. The date you die. 4. The date you begin working for an employer other than your Employer, or become self-employed. 5. The date long term disability benefits become payable to you under a group long term disability policy issued by us. ST.BE.01 PREDISABILITY EARNINGS Your Predisability Earnings will be based on your earnings in effect on your last full day of Active Work unless a different date applies (see Coverage Features). Any subsequent change in your earnings will not affect your Predisability Earnings. Predisability Earnings means your weekly rate of earnings from your Employer, including: 1. Contributions you make through a salary reduction agreement with your Employer to: a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2. Commissions averaged over the Earnings Period shown in the Coverage Features or over the period of your employment if less than the Earnings Period. 3. Shift differential pay. 4. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Predisability Earnings does not include: Printed 7/1/2003 5

10 1. Bonuses. 2. Overtime pay. 3. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. 4. Any other extra compensation. If you are paid on an annual contract basis, your weekly rate of earnings is based on one fifty-second (1/52nd) of your annual contract salary. If you are paid hourly, your weekly rate of earnings is based on your hourly pay rate multiplied by the number of hours you are regularly scheduled to work per week, but not more than 40 hours. If you do not have regular work hours, your weekly rate of earnings is based on the average number of hours you worked per week during the preceding 52 weeks (or during your period of employment if less than 52 weeks), but not more than 40 hours. ST.PD.14 Deductible Income means: DEDUCTIBLE INCOME 1. Your Work Earnings, as described in the Return To Work Incentive. 2. Any amount you receive or are eligible to receive because of your disability under a state disability income benefit law or similar law. 3. Any disability or retirement benefits you receive under your Employer's retirement plan. 4. Any amount you receive by compromise, settlement, or other method as a result of a claim for any of the above, whether disputed or undisputed. ST.DI.01X A. Weekly Equivalents RULES FOR DEDUCTIBLE INCOME Each week we will determine your STD Benefit using the Deductible Income for the same weekly period, even if you actually receive the Deductible Income in another week. If you are paid Deductible Income in a lump sum or by a method other than weekly, we will determine your STD Benefit using a prorated amount. We will use the period of time to which the Deductible Income applies. If no period of time is stated, we will use a reasonable one. B. Your Duty To Pursue Deductible Income You must pursue Deductible Income for which you may be eligible. We may ask for written documentation of your pursuit of Deductible Income. You must provide it within 60 days after we mail you our request. Otherwise, we may reduce your STD Benefits by the amount we estimate you would be eligible to receive upon proper pursuit of the Deductible Income. C. Pending Deductible Income We will not deduct pending Deductible Income until it becomes payable. You must notify us of the amount of the Deductible Income when it is approved. You must repay us for the resulting overpayment of your claim. See Claims. ST.RU.01 Printed 7/1/2003 6

11 BENEFITS AFTER INSURANCE ENDS OR IS CHANGED Your right to receive STD Benefits for a period of Disability which begins while you are insured will not be affected by: 1. Termination of the Group Policy after you become Disabled; 2. Termination of your insurance while the Group Policy remains in force; or 3. Any amendment to the Group Policy approved after the date you become Disabled. ST.BA.01 EFFECT OF NEW DISABILITY If a period of Disability is extended by a new cause while STD Benefits are payable, STD Benefits will continue while you remain Disabled. However, 1 and 2 below will apply. 1. STD Benefits will not continue beyond the end of the original Maximum Benefit Period. 2. All provisions of the Group Policy, including the Exclusions and Limitations sections will apply to the new cause of Disability. ST.ND.01 A. War EXCLUSIONS You are not covered for a Disability caused or contributed to by War or any act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature. B. Intentionally Self-Inflicted Injury You are not covered for a Disability caused or contributed to by an intentionally self-inflicted Injury, while sane or insane. C. Work Related You are not covered for a Disability arising out of or in the course of any employment for wage or profit. ST.EX.01 A. Care Of A Physician LIMITATIONS You must be under the ongoing care of a Physician during the Benefit Waiting Period. No STD Benefits will be paid for any period of Disability when you are not under the ongoing care of a Physician. B. Occupational Benefits No STD Benefits will be paid for any period when you are eligible to receive benefits under a workers' compensation law or similar law. If your claim for these benefits is accepted, compromised or settled (whether disputed or undisputed), you must repay us for the full amount of any payments we make to you while your claim for occupational benefits is pending. Printed 7/1/2003 7

12 C. Paid Sick Leave No STD Benefits will be paid for any period when you are receiving paid sick leave from your Employer. D. Working No STD benefits will be paid for any period: (a) when you are working for wage or profit for any employer other than your Employer; or (b) when you are self-employed. This limitation applies whether you are working in your own or another occupation. ST.LM.01 A. Filing A Claim CLAIMS Claims should be filed on our forms. If you do not receive our forms within 15 days after you ask for them, you may submit your claim in a letter to us. The letter should include the date Disability began, and the cause and nature of the Disability. B. Time Limits On Filing Proof Of Loss You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period. If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one year after that 90-day period. If Proof Of Loss is filed outside these time limits, your claim will be denied. These limits will not apply while you lack legal capacity. C. Proof Of Loss Proof Of Loss means written proof that you are Disabled and entitled to STD Benefits. Proof Of Loss must be provided at your expense. D. Documentation Completed claims statements, a signed authorization for us to obtain information, and any other items we may reasonably require in support of a claim must be submitted at your expense. If the required documentation is not provided within 45 days after we mail our request, your claim may be denied. E. Investigation Of Claim We may investigate your claim at any time. At our expense, we may have you examined at reasonable intervals by specialists of our choice. We may deny or suspend STD Benefits if you fail to attend an examination or cooperate with the examiner. F. Time Of Payment We will pay STD Benefits within 60 days after you satisfy Proof Of Loss. STD Benefits will be paid to you at the end of each week you qualify for them. STD Benefits remaining unpaid at your death will be paid to your estate. G. Overpayment Of Claim We will notify you of the amount of any overpayment of your claim under any group disability insurance policy issued by us. You must immediately repay us. You will not receive any STD Benefits until we have been repaid in full. In the meantime, any STD Benefits paid, including the Minimum STD Benefit, will be applied to reduce the amount of the overpayment. We may charge you interest at the legal rate for any overpayment which is not repaid within 30 days after we first mail you notice of the amount of the overpayment. Printed 7/1/2003 8

13 H. Notice Of Decision On Claim We will evaluate your claim promptly after you file it. Within 45 days after we receive your claim we will send you: (a) a written decision on your claim; or (b) a notice that we are extending the period to decide your claim for 30 days. Before the end of this extension period we will send you: (a) a written decision on your claim; or (b) a notice that we are extending the period to decide your claim for an additional 30 days. If an extension is due to your failure to provide information necessary to decide the claim, the extended time period for deciding your claim will not begin until you provide the information or otherwise respond. If we extend the period to decide your claim, we will notify you of the following: (a) the reasons for the extension; (b) when we expect to decide your claim; (c) an explanation of the standards on which entitlement to benefits is based; (d) the unresolved issues preventing a decision; and (e) any additional information we need to resolve those issues. If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may decide your claim based on the information we have received. If we deny any part of your claim, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision. d. A description of any additional information needed to support your claim. e. Information concerning your right to a review of our decision. f. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA if your claim is denied on review. I. Review Procedure If all or part of a claim is denied, you may request a review. You must request a review in writing within 180 days after receiving notice of the denial. You may send us written comments or other items to support your claim. You may review and receive copies of any non-privileged information that is relevant to your request for review. There will be no charge for such copies. You may request the names of medical or vocational experts who provided advice to us about your claim. The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based on a medical judgement, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original medical judgement and will not be subordinate to that person. Our review will include any written comments or other items you submit to support your claim. We will review your claim promptly after we receive your request. Within 45 days after we receive your request for review we will send you: (a) a written decision on review; or (b) a notice that we are extending the review period for 45 days. If the extension is due to your failure to provide information necessary to decide the claim on review, the extended time period for review of your claim will not begin until you provide the information or otherwise respond. If we extend the review period, we will notify you of the following: (a) the reasons for the extension; (b) when we expect to decide your claim on review; and (c) any additional information we need to decide your claim. Printed 7/1/2003 9

14 If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may conclude our review of your claim based on the information we have received. If we deny any part of your claim on review, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision. d. Information concerning your right to receive, free of charge, copies of non-privileged documents and records relevant to your claim. e. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA. The Group Policy does not provide voluntary alternative dispute resolution options. However, you may contact your local U.S. Department of Labor Office and your State insurance regulatory agency for assistance. J. Assignment The rights and benefits under the Group Policy are not assignable. ST.CL.13 ALLOCATION OF AUTHORITY Except for those functions which the Group Policy specifically reserves to the Policyholder, we have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in its administration, interpretation, and application. Our authority includes, but is not limited to: 1. The right to resolve all matters when a review has been requested; 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it; 3. The right to determine: a. Eligibility for insurance; b. Entitlement to benefits; c. Amount of benefits payable; d. Sufficiency and the amount of information we may reasonably require determining a., b., or c., above. Subject to the review procedures of the Group Policy, any decision we make in the exercise of our authority is conclusive and binding. ST.AL.01 TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No such action may be brought more than three years after the earlier of: Printed 7/1/

15 1. The date we receive Proof Of Loss; and 2. The end of the period within which Proof Of Loss is required to be given. ST.TL.01 A. Incontestability Of Member's Insurance INCONTESTABILITY PROVISIONS Any statement you make to obtain insurance is a representation and not a warranty. No misrepresentation by you will be used to reduce or deny your claim unless: 1. Your insurance would not have been approved if we had known the truth; and 2. We have given you a copy of a written instrument signed by you which contains your misrepresentation. After your insurance has been in effect for two years, we will not use a misrepresentation by you to reduce or deny your claim, unless it was a fraudulent misrepresentation. B. Incontestability Of Group Policy Any statement made by the Policyholder or Employer to obtain the Group Policy is a representation and not a warranty. No misrepresentation by the Policyholder or Employer will be used to deny a claim or to deny the validity of the Group Policy unless: 1. The Group Policy would not have been issued if we had known the truth; and 2. We have given the Policyholder or Employer a copy of a written instrument signed by the Policyholder or Employer which contains the misrepresentation. The validity of the Group Policy will not be contested after it has been in force for two years, except for nonpayment of premiums or fraudulent misrepresentations. ST.IN.01 WHEN YOUR INSURANCE BECOMES EFFECTIVE The Coverage Features states whether your insurance is Contributory or Noncontributory. A. Noncontributory Insurance Subject to the Active Work Provisions, your Noncontributory insurance becomes effective on the date you become eligible. B. Contributory Insurance You must apply in writing for Contributory insurance and agree to pay premiums. Subject to the Active Work Provisions, your insurance becomes effective on: 1. The date you become eligible, if you apply on or before that date; 2. The date you apply, if you apply within 31 days after you become eligible; or 3. The date we approve your Evidence Of Insurability, if you apply more than 31 days after you become eligible (late application). Printed 7/1/

16 C. Insurance Subject To Evidence Of Insurability Subject to the Active Work Provisions, insurance subject to Evidence Of Insurability becomes effective on the date we approve Evidence Of Insurability. D. Takeover Provisions 1. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy. 2. You must submit satisfactory Evidence Of Insurability to become insured for insurance if you were eligible for insurance under the Prior Plan for more than 31 days but were not insured. ST.EF.02 A. Active Work Requirement ACTIVE WORK PROVISIONS If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled effective date of your insurance, your insurance will not become effective until the day after you complete one full day of Active Work as an eligible Member. Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business. You will also meet the Active Work requirement if: 1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day; 2. You were Actively At Work on your last scheduled work day before the date of your absence; and 3. You were capable of Active Work on the day before the scheduled effective date of your insurance. B. Changes In Insurance This Active Work requirement also applies to any increase in your insurance. However, if you return to Active Work during a period of Disability or Temporary Recovery (see Temporary Recovery), you will not qualify for any change in insurance caused by a change in: 1. Your status as a member of a class; 2. The rate of earnings used to determine your Predisability Earnings; or 3. The terms of the Group Policy. ST.AW.02 Your insurance ends automatically on the earliest of: WHEN YOUR INSURANCE ENDS Printed 7/1/

17 1. The date the last period ends for which you made a premium contribution, if your insurance is Contributory. 2. The date the Group Policy terminates. 3. The date your employment terminates. 4. The date you cease to be a Member. However, if you cease to be a Member because you are not working the required minimum number of hours, your insurance will be continued during the following periods, unless it ends under 1 through 3 above. a. While your Employer is paying you at least the same Predisability Earnings paid to you immediately before you ceased to be a Member. b. During the Benefit Waiting Period and while STD Benefits are payable. c. During a leave of absence if continuation of your insurance under the Group Policy is required by a state-mandated family or medical leave act or law. d. During any other leave of absence approved by your Employer in advance and in writing and scheduled to last the Leave Of Absence Period shown in the Coverage Features. ST.EN.16 REINSTATEMENT OF INSURANCE If your insurance ends, you may become insured again as a new Member. However, the following will apply. 1. If your insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 2. If your insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If your insurance ends because you are on a federal or state mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state mandated family or medical leave act or law. ST.RE.01 DEFINITIONS Benefit Waiting Period means the period you must be continuously Disabled before STD Benefits become payable. No STD Benefits are payable for the Benefit Waiting Period. See Coverage Features. Contributory means you pay all or part of the premium for your insurance. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See Coverage Features. Providing Evidence Of Insurability means you must: Printed 7/1/

18 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about your health; 3. Undergo a physical examination, if required by us, which may include blood testing; and 4. At your expense, provide any additional information about your insurability that we may reasonably require. Group Policy means the group short term disability insurance policy issued by us to the Policyholder and identified by the Group Policy Number. Injury means an injury to your body. Maximum Benefit Period means the longest period for which STD Benefits are payable for any one period of continuous Disability, whether from one or more causes. It begins at the end of the Benefit Waiting Period. No STD Benefits are payable after the end of the Maximum Benefit Period, even if you are still Disabled. See Coverage Features. Noncontributory means the Policyholder or Employer pays the entire premium for your insurance. Physician means a licensed medical professional, other than yourself, acting within the scope of the license. Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Prior Plan means your Employer's group short term disability insurance plan in effect on the day before the effective date of your Employer's coverage under the Group Policy and which is replaced by the Group Policy. Sickness means your sickness, illness, or disease. STD Benefit means the weekly benefit payable to you under the terms of the Group Policy. ST.DF.01 Printed 7/1/